1277 Io3/zF\/�A/ / / �{
.I �f'�/ Y�FS �. LM MU J9
NO. eTer `
® '4Q'ICAT V}` FOR GAS PERMIT
FEB 9 �grjeF F CUPERTINO
Date IpL Permit No. 1 Z
(� CITY 0 "v Fee $ / So
Y Application is hereby made to the City of Cupertino for a permit to install gas pipes
and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
a,
v
aUse of Premises
l Own— �m�h` ' Address
S
By Address
ZI
PhoneLk��
Approved
PLUMBING INSP R
Remarks (Check ✓)
Tyeean
of Appliance Units Fees II New Replace Relocate
Gas Rges
Wall Heaters
GasPlates
Circulating Heaters IL
Blower Furnaces
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit—�—II
Floor Furnace
Miscellaneous � � _j� � i
NAME TYPE)
I I
I I I I _
I J I I
pp mnce Fees � I II I I
Inspected and Approved ..............:...I...............................................
DATE INSPECTOR
HOUSE GAS PIPING
Number of Outlets Size of Main I _
GasPigi g FFees Tested and Approved�% '1A..6� . ..........._............................
DATE INSPECTOR